3 Similarity Coding Steps remain the sameIdentify all main terms in diagnostic statementsApply your knowledge of A& P and pathology, pharmaceuticals, and treatmentsMain terms are USUALLY NounsIdentify modifiers in diagnostic statementModifiers are USUALLY adjectivesLocate main terms in AIIf terms not identical, use your medical terminology knowledge to translate from documentation to code book

4 Coding Steps Locate modifiers in subterms under main termsCheck for special instructions or cross-referencesTENTATIVELY select a codeTurn to code category in TLCheck for any instructional notes for code category/chapterApply your knowledge of code book conventionsAssign code when all elements of dx statement accounted for and code verified in TL

5 Similarities ICD-10-CM = Same hierarchical structure1st three characters are category of codeAll codes within same category have similar traitsAlphabetic Index to Diseases and InjuriesSame format and use as ICD-9-CM AITable of Drugs and ChemicalsNeoplasm TableIndex to External Causes

7 DifferencesCode titles & language that reflect accepted clinical practiceCodes able to reveal more about quality of care, so data can be used in more meaningful ways to betterUnderstand complicationsDesign clinically robust algorithmsTrack outcomes of careInformation for clinical decision making and outcome research

8 DifferencesICD-10-CM consists of 21 chapters compared to 17 chapters in ICD-9-CMICD-9-CM’s V and E codes incorporated into main classification in ICD-10-CMReflecting current medical knowledge, certain diseases reclassified (reassigned) to more appropriate chapter in ICD-10-CMInjuries classified by site and THEN type

9 Improved Excludes notesExcludes1 = NOT coded hereExcluded code is NEVER used with codeTwo conditions cannot occur togetherExcludes2 = NOT INCLUDED hereExcluded condition is NOT part of condition represented by codeAcceptable to use both codes together IF patient has both conditions

12 ICD-10- CM I.C.2.c.1, Anemia associated with malignancyWhen admission/encounter is for management of an anemia associated with the malignancy, and the treatment is only for anemia, the appropriate code for the malignancy is sequenced as the principal or first-listed diagnosis followed by the appropriate code for the anemia (such as code D63.0, Anemia in neoplastic disease)Reverse of ICD-9-CM

13 ICD-10-CM I.C.2.c.2Anemia associated with chemotherapy, immunotherapy and radiation therapyWhen admission/encounter is for mgt of an anemia associated with adverse effect of administration of chemotherapy or immunotherapy and the only treatment is for the anemia, the anemia code is sequenced first followed by appropriate codes for neoplasm & adverse effect (T45.1X5)Same sequencing as ICD-9-CM

14 ICD-10-CM I.C.2.c.2When admission/encounter is for mgt of anemia associated with adverse effect of radiotherapy, anemia code should be sequenced first, followed by appropriate neoplasm code and code Y84.2, Radiological procedure and radiotherapy as cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure.

20 Neoplasm Example 250-y-o female diagnosed w/ left breast carcinoma four years ago, when she had left mastectomy performed w/ chemotherapy. She has been well since then w/ no further tx except for yearly checkups. Pt is now being seen w/visual disturbances, dizziness, headaches, and blurred vision.Workup revealed metastasis to brain, accounting for symptoms. Identified as metastatic from breast, not new primary.

23 Example 2 ICD-10-CM ExplanationEncounter for metastatic brain caPreviously excised primary ca w/ no further tx: therefore, coded hx of breast cancerPrevious mastectomy, so code for acquired absence of breast. Laterality can be specified in Z90.1 subcategoryDocumented brain metastasis caused symptoms, so not codedCode available for hx chemotherapy IF facility codes to that level of detail

25 Coding Guidelines For Skin chapter in both ICD-9 and ICD-10Only Pressure ulcersSeveral identicalSome different for ICD-10-CMDue to more specific codes availableTherefore, coder will apply general coding guidelines and codebook conventions when coding other skin conditions

51 Example 4 ExplanationL97 code may be used as PrDx/First listed code IF no underlying condition documentedIF one of underlying conditions listed hereis documented w/ lower extremity ulcerCausal condition should be assumedatherosclerosis of lower extremitieschronic venous hypertensiondiabetic ulcers, postphlebitic syndrome, varicose ulcerCodes must be listed in this order

63 Skin Example 7 ExplanationReason, after study, for encounter is dermatitis; adverse effect of RamiprilInstructional note in Tabular at L27.1Use add’al code for adverse effect, if applicable, to id drug (T36-T50 with 5th/6th character 5)T46.4X5A sequenced as 2ndary dx7th character of A indicates initial encounter for conditionDocumentation = localized dermatitisDocumentation doesn’t = long-term use of drug

64 Skin Example 8Pt seen w/extensive inflammation & irritation of skin of upper eyelids & under eyebrows; spreading to temples & forehead. During H&P, she stated recently used new eye cosmetics. Pt seen during prior visit for cystic acne.

68 Skin Example 8 ExplanationReason for encounter was contact dermatitis due to adverse reaction to use of new eye cosmetics7th character A = initial encounter for condition.Several different Index terms for dermatitis.

69 Skin Example 8 ExplanationIrritant contact dermatitis, but not allergicIndex = Contact, irritant, due to cosmetics, L24.3.Contact, allergic, due to cosmetics = L23.2Contact dermatitis (not documented as irritant) due to cosmetics is coded L25.0Careful review of record and Index required

71 Dermal Appendages Office Visit Example54-y-o female presents w/ infected cuticle on left thumbnail. Pt states started about one week ago. She denies any discharge from nail but throbbing pain at night. She is a bartender, hands frequently in water. Denies any trauma to hand. No possibility of fracture. No nausea, vomiting or diarrhea, fever or chills.Pt has cough. She has smoked pack/day for past 20+ years. Cough is typical and sometimes productive of whitish clear sputum.

72 Office Visit ExampleAllergies: Penicillin & iodine both which produce hives.Social Hx: Drinks 2 beers/day. No illicit drug use.ROS: Pt never had chest x-ray. Up to date on Pap smears and mammogram.PE: Blood pressure is 118/66. Pulse 70. Respiration 12. Temp is Lungs are clear to auscultation. No rales, rhonchi, or wheezing. Heart is RRR. Abdomen is soft, nontender, and nondistended. To the lateral aspect of the left thumbnail bed there is increased swelling and erythema with no discharge noted. There is exquisite tenderness on palpation.

76 ICD-10-CM ExplanationCellulitis of finger (Thumb NOT specified) is L with a sixth digit of 2 for left finger.The Index does NOT provide entry for tobacco or nicotine under Abuse Main Term, but category J41.0 does direct coder to use add’l code to id tobacco use, Z72.0.

79 PU CasePt brought into ED by ambulance, after his daughter found him at home lying on floor, unconscious. ED room physician admits him w/ Dx of pneumonia, fall with long lie, dehydration, and altered mental status.By 2nd hospital day, he developed new pressure ulcer over right lateral malleolus.Examination of ulcer shows a round, 3 cm black eschar that is debrided to an ulcer that extends through dermis.

87 Initial Encounters (A)Initial encounter 7th character used while patient receiving active treatment for conditionSurgical treatmentEmergency department encounterEvaluation and treatment by new physicianCan be used each time pt actively treated for same condition

88 Subsequent Encounter (D)Subsequent encounter 7th Character used for encounters after patient received active tx for conditionNow receiving routine care for condition during healing or recovery phaseCast change or removalRemoval of external or internal fixation deviceMedication adjustmentOther aftercare & follow-up visits following treatment of injury or condition

89 Sequela Encounter (S)Sequela 7th character used for complications or conditions directly due to condition, such as scar formation after burn (Scar is sequela).MUST use both injury code that caused sequela AND code for sequela itselfS added ONLY to injury code (burn), NOTsequela code (scar)Type of sequela (e.g., scar) sequenced 1st, then injury code

90 Aftercare CodesAftercare Z codes NOT used for aftercare for conditions when 7th seventh characters available to id subsequent episodes of careFor aftercare of injury, assign acute injury code with 7th character for “subsequent encounter.”

91 Adverse Effects and Poisonings (T36-T50)Nature of adverse effect firstFollowed by code for drugPoisoningsPoisoning CodeCode(s) for all manifestationsSame sequencing as ICD-9-CM

92 T36-T50Includes:Adverse effect of correct substance properly administered (hypersensitivity, reaction, etc.)Poisoning byOverdose of substanceWrong substance given or taken in errorUnderdosing by (NOT in ICD-9-CM)(inadvertently) (deliberately) taking less substance than prescribed or instructedUse add’l code for INTENT OF underdosingFailure to dose during medical/surgical carePt’s underdosing

93 Multiple InjuriesCode for most severe injury is sequenced as Principal DiagnosisDetermined by physicianTreatment provided

101 ER Burn Example Pt seen in ER today for burn of right ankle.Pt was cooking dinner in kitchen of her single family home & carrying pot of boiling hot liquid that splashed on her ankle.Physician states DX as:2nd degree burn, right ankle.

104 ICD-10-CM ExplanationDocumentation states that patient was cooking dinner at home.External cause status for this is leisure.Burn code and external cause code are coded with 7th character AInitial encounter because pt seen in ED today

106 Delayed HealingDelayed treatment & healing tends to lead to infections, which = complicated open woundNO strict definition of delayed healing or txEx: If pt delays seeking treatment by one week, & wound does not appear to be healing appropriately, then use complicated codeIf coder NOT sure, query physician

107 Open Wounds Coding directive before category 860Description ‘with open wound,’ used in 4th-digit subdivisions, includes those w/ mention of infection or foreign body.Do NOT code Superficial injuries (abrasions, contusions, etc.) when associated with more severe injuries of same site.

108 Cellulitis Vs Open WoundSequencing depends on circumstances of admission/encounterPt suffered laceration of lower leg while hiking 2 days ago; came to hospital on his return.Cellulitis beginning to develop. Wound cleansed, nonexcisional debridement, & antibiotics started for cellulitis.891.1, CellulitisPt suffered minor puncture injury to finger removing staple at office. 5 days later, admitted to hospital because of cellulitis of finger, tx with IV.Wound didn’t require tx, therefore not codedCellulitis

109 Wounds ICD-10-CM Injuries are classified by Body SITE, then typeOpen wounds consistent across body sitesTypes of open wounds classified in ICD-10-CMLaceration without foreign bodyLaceration with foreign bodyPuncture wound without foreign bodyPuncture wound with foreign bodyOpen biteUnspecified open wound

114 Poisoning ExampleWoman admitted for intentional overdose of marijuana & cocaine. She sustained fall, resulting in left cheek & scalp laceration.After she stabilizes medically, she will be transferred to a psychiatric unit.

117 Poisoning Example ICD-10-CM ExplanationIf overdose of drug intentionally taken or administered and resulted in drug toxicity, coded as poisoning.7th character is required for all codes in this Example.

122 Destruction of LesionsAblation ofB9Premalignant orMalignant tissueBy any combination ofElectrosurgeryCryosurgeryLaserChemical txDestruction includes local anesthesiaNO tissue left for pathology = DestructionIF there is pathology report, was NOT destruction

126 Flaps and Grafts Involve moving normal tissue from one site to anotherDonor site = where tissue originatesRecipient site = where it is relocatedSurgical preparation of recipient site is reported separately

128 Free skin grafts Defined by size, location of recipient site (defect area), and type of graftReported separately when done in conjunction with other proceduresMastectomy , etc.

129 Laser Surgery Usually included in “destruction by any method.”IF using laser significantly alters procedure performance, use codes that specifically identify laser in their descriptions

130 Wound RepairSurgical closure of wound; may be caused by injury/ trauma OR surgically created defect3 categories of wounds –simple, intermediate, complex,described by anatomic site, then sizeAdhesive strips ONLY = E/M code ONLY

136 CPT Wound Example 2a patient has a contaminated laceration on the foot. When the patient was first seen, the orthopaedic surgeon débrided the laceration. Several days later, the patient was taken to the operating room and the surgeon performed a surface area débridement to prepare the wound for a complex closure. The patient was not in a global period.

138 Alternative coding format reports units for add-on code, 13122This format should be used only if payer requiresWhen all units are reported on one line, fees should reflect number of units.Because single line for code reflects 3 units, fees are tripled.*Some payers may require use of - 59 on 2nd-5th add-on code, while others may require add-on code reported in units

140 Wound Coding Answer Document neededAnatomic locationDepth of débridementSurface area of wound(s)Report each wound separately because depths of débridement not the sameUse -59 with both distinct second procedure and associated add-on code